Fasciolariidae (Gastropoda: Neogastropoda) of French Guiana and nearby regions, with descriptions of two new species and comments on marine zoogeography of northeastern South America.

The fasciolariid fauna from two expeditions to French Guiana is examined and augmented with published records and material of other collections from the Guianas and northeastern Brazil. Twelve species of Fasciolaria and Aurantilaria (Fasciolariinae), Aristofusus, Lyonsifusus and Fusinus s.l. (Fusininae), and Lamellilatirus and Polygona (Peristerniinae) are reported and discussed. Nine species are represented in expedition collections, and reports of three other species are evaluated. Two morphologically distinct species of Lamellilatirus are described as new; type localities of both are off French Guiana, 114-118 m. Ten Guianan fasciolariids range variously northward to Caribbean South America and the Lesser Antilles and southward to Ceará, Brazil; one other extends into the northern Caribbean, and one extends southward to Rio de Janeiro, Brazil.

SCORE - Leveling the Playing Field for Surgical Training Programs.

OBJECTIVE: The Surgical Council on Resident Education (SCORE) web portal provides a uniform, comprehensive, competency-based curriculum for general surgery residents. One of SCORE's principal founding goals was to provide equal opportunity for access of educational resources at programs across the United States which reported having a range of resources. We aimed to determine if there was a difference in portal usage by trainees in independent versus university programs, and across geographic areas. METHODS: Using analytic software, we measured SCORE usage by trainees in 246 subscribing programs from August 2015 to March 2017. The primary outcome was the average duration of SCORE use per login. Secondary outcomes were the geographic region of each program, and university versus independent designation. Encounters lasting >8 hours (comprising 7% of the data set) were excluded to eliminate the likelihood of failure to log off the portal. RESULTS: Over the study period, there were 669,501 SCORE sessions with 22% of these lasting 1 to 5 minutes, 33% lasting 6 to 30 minutes, and 28% lasting 31 to 120 minutes. Between the university (64.4% of encounters) and independent (35.6% of encounters) program types, there was no significant difference in average visit length overall, or in the normally-distributed designated time categories (t test -1.0, p = 0.3). When mean encounter length per program was compared by geographic regions, there was also no difference in the three time categories (ANOVA p = 0.9, 0.2, and 0.5, respectively). CONCLUSIONS: Most (50%) of SCORE encounters lasted 30 minutes of less, confirming prior work that shows trainees use the portal in relatively short bursts of activity. While there were more encounters from university program trainees (proportional with their greater numbers), the mean duration of an individual encounter did not significantly differ by program type as a whole or by region. These results suggest that SCORE is an equally accessible educational resource and is used by surgical trainees, regardless of program type or geographic region.

Home Energy Management System Incorporating Heat Pump Using Real Measured Data.

The demand for electricity has been rising significantly over the past years and it is expected to rise further in the coming years due to economic and societal development. Smart grid technology is being developed in order to meet the rising electricity requirement. In order for the smart grid to perform its full functions, the Energy Management Systems (EMSs), especially Home Energy Management Systems (HEMS) are essential. It is necessary to understand the energy demand of the loads and the energy supply either from the national grid or from renewable energy technologies. To facilitate the Demand Side Management (DSM), Heat Pumps (HP) and air conditioning systems are often utilised for heating and cooling in residential houses due to their high-efficiency power output and low CO2 emissions. This paper presents a program for a HEMS using a Particle Swarm Optimisation (PSO) algorithm. A HP is used as the load and the aim of the optimisation program is to minimise the operational cost, i.e., the cost of electricity, while maintaining end-user comfort levels. This paper also details an indoor thermal model for temperature update in the heat pump control program. Real measured data from the UK Government's Renewable Heat Premium Payment (RHPP) scheme was utilised to generate characteristic curves and equations that can represent the data. This paper compares different PSO variants with standard PSO and the unscheduled case calculated from the data for five winter days in 2019. Among all chosen algorithms, the Crossover Subswarm PSO (CSPSO) achieved an average saving of 25.61% compared with the cost calculated from the measured data with a short search time of 1576 ms for each subswarm. It is clear from this work that there is significant scope to reduce the cost of operating a HP while maintaining end user comfort levels.

Reassignments to the Genus Marmorofusus Snyder amp; Lyons, 2014 (Neogastropoda: Fasciolariidae: Fusininae) of species from the Red Sea, Indian Ocean, and southwestern Australia.

Twelve species from the Bay of Bengal, the Red Sea, the western Indian Ocean, and southwestern Australia are reclassified in Marmorofusus. These include: Murex undulatus Gmelin, 1791, a senior synonym of Murex variegatus Perry, 1811 and Fusus laticostatus Deshayes, 1831, formerly regarded as a junior synonym of Marmorofusus nicobaricus (Röding, 1798); Murex verrucosus Gmelin, 1791 (synonyms Fusus tuberculatus Anton, 1839 non Lamarck, 1822, F. marmoratus Philippi, 1846 and F. rudicostatus G.B. Sowerby II, 1880); F. polygonoides Lamarck, 1822 (synonym F. biangulatus Deshayes, 1833); F. tuberculatus (Lamarck, 1822) (synonyms Fusus indicus Anton, 1839, F. maculiferus Tapparone Canefri, 1875, Fusinus t. priscai Bozzetti, 2013 and F. t. fuscobandatus Bozzetti, 2017); Fusus philippii Jonas in Philippi, 1846, an earlier name for Fusus tessellatus G.B. Sowerby II, 1880 (other probable synonyms Fusus exilis Menke, 1843, non Conrad, 1832 and Fusinus dampieri Finlay, 1930, replacement name for F. exilis Menke); Fusus oblitus (Reeve, 1847) (synonym Fusus turrispictus Hedley, 1918); F. leptorhynchus Tapparone Canefri, 1875 (synonym F. subquadratus G.B. Sowerby II, 1880), Fusinus vercoi Snyder, 2004; F. wellsi Snyder, 2004; F. brianoi Bozzetti, 2006; F. verbinneni Snyder, 2006; and F. bishopi Petuch Berschauer, 2017. Fusus toreuma Deshayes, 1843, sometimes misidentified as M. tuberculatus, is a member of the Fusinus colus (Linnaeus, 1758) species group.

Approach to Evaluating the Multimorbid Patient with Cardiovascular Disease Undergoing Noncardiac Surgery.

Older patients undergo more inpatient and outpatient procedures than do younger individuals, and their risk of suffering undesired outcomes is greater. The performance of a productive preoperative assessment entails more than the application of the sundry clinical practice guidelines relating to a patient's various medical diagnoses. A better approach involves adoption of a physiologically integrated, whole-person assessment that takes into account the patient's cognitive function, mood, physical function and mobility (including the possibility of frailty), social support, nutritional status, and medication use. This article outlines such an approach and highlights the many gaps in the current evidence base.

Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These "Geriatric Emergency Department Guidelines" represent the first formal society-led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost-effectiveness studies, and institutional credentialing.

Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and strained healthcare systems. In response, geriatric emergency medicine clinicians, educators, and researchers collaborated with the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations, equipment, policies, and protocols. These Geriatric Emergency Department Guidelines represent the first formal society-led attempt to characterize the essential attributes of the geriatric ED and received formal approval from the boards of directors of each of the four societies in 2013 and 2014. This article is intended to introduce emergency medicine and geriatric healthcare providers to the guidelines while providing recommendations for continued refinement of these proposals through educational dissemination, formal effectiveness evaluations, cost-effectiveness studies, and eventually institutional credentialing.

Preoperative assessment of the older patient: a narrative review.

IMPORTANCE: Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical risks, and individualized optimization strategies are essential. OBJECTIVE: To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed. EVIDENCE ACQUISITION: A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline). Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years. RESULTS: This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n = 1,422,433 patients) and 26 that examined factors associated with surgical complications (n = 136,083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio [HR], 1.26 [95% CI, 1.06-1.49] to 5.77 [95% CI, 1.55-21.55]), 10% to 17% for malnutrition (adjusted odds ratio [OR], 0.88 [95% CI, 0.78-1.01] to 59.2 [95% CI, 3.6-982.9]), and 11% to 41% for institutionalization (adjusted OR, 1.5 [95% CI, 1.02-2.21] to 3.27 [95% CI, 2.81-3.81]).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, 0.99-1.04) to an adjusted OR of 18.7 (95% CI, 1.6-215.3) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, 1.04-1.16) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, 1.4-2.7) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, 1.2-239.8; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 [95% CI, 1.0-9.99] to 13.02 [95% CI, 5.14-32.98]). CONCLUSIONS AND RELEVANCE: Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making.

The genus Pustulatirus Vermeij and Snyder, 2006 (Gastropoda: Fasciolariidae: Peristerniinae) in the western Atlantic, with descriptions of three new species.

Western Atlantic species of the New World genus Pustulatirus Vermeij and Snyder, 2006 are revised. Types of previously named taxa are figured. Species recognized as valid include P. attenuata (Reeve, 1847), range uncertain; P. eppi (Melvill, 1891), Curagao; P. ogum (Petuch, 1979), northeastern Brazil; and P. virginensis (Abbott, 1958), Bahama Islands and eastern Caribbean Sea to Aruba. Latirus karinae Nowell-Usticke, 1969 is confirmed as ajunior subjective synonym of P. virginensis. Syrinx annulata Röding, 1798, treated as a Caribbean Pustulatirus by Vermeij and Snyder (2006), and Latirus annulatus Melvill, 1891 are regarded as species inquirenda. Three new species are described: P biocellatus, northeastern Brazil; P. utilaensis, Bay Islands, Honduras and northwestern Panamá; and P. watermanorum, Honduras continental shelf and offshore Colombian banks. Most western Atlantic Pustulatirus shells exhibit little intraspecific variability in morphology or color and occur within rather precise, well-defined ranges; an exception is P. virginensis, whose shells exhibit much variability in size, morphology and color.

Assessing challenges in end-of-life conversations with elderly patients with multiple morbidities.

INTRODUCTION: This study reports on physicians' experiences in conducting end-of-life conversations with elderly patients who suffered from multiple co-morbidities (MCM). Our hypothesis was that both the lack of prognostic certainty and the lack of good communication tools contributed to physicians' discomfort with conducting EOL conversations with patients and families of patients with these conditions especially when compared with patients and families of patients who had a single, clear terminal diagnosis (e.g. pancreatic cancer). METHODS: Focus group questions were semi-structured and explored three general themes: (1) differences between having an end-of-life conversation with patients/families with MCM versus those with a single, terminal diagnosis; (2) timing of the end-of-life conversation; and (3) approaches to the end-of-life conversation. RESULTS: Three themes emerged: (1) It is more difficult for them to have EOL conversations with patients with MCM and their families, as opposed to conversations with families and patients who have a clear, terminal diagnosis. (2) In deciding when to raise the subject of EOL care, participants reported that they rely on a number of physical and/or social signs to prompt these discussions. Yet a major reason for the difficulty that providers face in initiating these discussions with MCM patients and families is that there is a lack of a clear threshold or prompting event. (3) Participants mentioned three types of approaches to initiating EOL conversations: (a) direct approach, (b) indirect approach, (c) collaborative approach. CONCLUSION: Prognostic indicies and communication scripts may better prepare physicians to facilitate end-of-life conversations with MCM patients/families.

Adaptations to a new physical training program in the combat controller training pipeline.

OBJECTIVES: The United States Air Force combat controller (CCT) training pipeline is extremely arduous and historically has a high attrition rate of 70 to 80%. The primary objective of this study was to evaluate the impact of incorporating a 711 Human Performance Wing (HPW) / Biobehavior, Bioassessment, and Biosurveillance Branch (RHPF)-developed physical fitness-training program into the combat controller (CCT) 5-level training physical fitness program. METHODS: One-hundred-nine CCT trainees were tested and trained during their initial eight weeks at the 720th Special Tactics Training Squadron (STTS) at Hurlburt Field. Modifications to their physical training program were principally aimed at reducing overtraining and overuse injury, educating trainees and cadre on how to train smarter, and transitioning from traditional to "functional" PT. A battery of physiological measurements and a psychological test were administered prior to and immediately after trainees undertook an 8-week modified physical fitness training program designed to reduce overtraining and injury and improve performance. We performed multiple physical tests for cardiovascular endurance (VO2max and running economy), "anaerobic" capacity (Wingate power and loaded running tests), body composition (skinfolds), power (Wingate and vertical jump), and reaction time (Makoto eye-hand test). We used the Mental Toughness Questionnaire 48 (MTQ-48) for the psychological test. RESULTS: We observed several significant improvements in physical and physiological performance over the eight weeks of training. Body composition improved by 16.2% (p < 0.05). VO2max, time-to-exhaustion, and ventilatory threshold were all significantly higher after implementation of the new program than before it. We observed strong trends towards improvement in work accomplished during loaded running (p = 0.07) and in average power per body mass during lower body Wingate (p = 0.08). Other measures of lower body power did not change significantly over the training period, but did show mild trends towards improvement. Upper body average and peak power per kilogram of body mass both improved significantly by 5.8% and 8.1%, respectively. Reaction time was significantly better posttraining as demonstrated by a 7% improvement during the reactive test. Reactive accuracy also improved significantly with the post test accuracy percentage jumping from 61% to 76%. Furthermore, overuse injuries, a major source of attrition fell by a dramatic 67%. CONCLUSIONS: The modifications resulted in significant improvement in trainees? graduation rate. In the eight classes prior to implementation of these changes, average CCT graduating class size was nine trainees. For the eight classes following the changes, average CCT graduating class rose to 16.5 trainees, an increase of 83%. Due to its success, STTS leadership expanded the modifications from the eight weeks prior to CDS to include the entire second year of the pipeline.

Assessment of a chief complaint-based curriculum for resident education in geriatric emergency medicine.

INTRODUCTION: We hypothesized that a geriatric chief complaint-based didactic curriculum would improve resident documentation of elderly patient care in the emergency department (ED). METHODS: A geriatric chief complaint curriculum addressing the 3 most common chief complaints-abdominal pain, weakness, and falls-was developed and presented. A pre- and postcurriculum implementation chart review assessed resident documentation of the 5 components of geriatric ED care: 1) differential diagnosis/patient evaluation considering atypical presentations, 2) determination of baseline function, 3) chronic care facility/caregiver communication, 4) cognitive assessment, and 5) assessment of polypharmacy. A single reviewer assessed 5 pre- and 5 postimplementation charts for each of 18 residents included in the study. We calculated 95% confidence and determined that statistical significance was determined by a 2-tailed z test for 2 proportions, with statistical significance at 0.003 by Bonferroni correction. RESULTS: For falls, resident documentation improved significantly for 1 of 5 measures. For abdominal pain, 2 of 5 components improved. For weakness, 3 of 5 components improved. CONCLUSION: A geriatric chief complaint-based curriculum improved emergency medicine resident documentation for the care of elderly patients in the ED compared with a non-age-specific chief complaint-based curriculum.

Carboplatin plus gemcitabine repeating doublet therapy in recurrent breast cancer.

PURPOSE: The combination of cisplatin plus gemcitabine is active in metastatic breast cancer. Carboplatin plus gemcitabine, widely used in ovarian and non-small-cell lung cancers, has also been used in breast cancer. This trial examined the efficacy and toxicity of split-dose carboplatin plus gemcitabine in advanced breast cancer. PATIENTS AND METHODS: Patients with measurable disease, recurrent after adjuvant and < or = 1 previous treatment for systemic disease, received carboplatin area under the curve = 2.0 (Calvert) plus gemcitabine 800 mg/m2, both drugs administered days 1 and 8 every 21 days. Of 15 patients accrued, 13 are fully evaluable. RESULTS: There were 2 complete (13.3%) and 6 partial (40%) responses, for an overall response rate by intention to treat of 53.3% (95% CI, 28%-82%). The median time to progression was 4.5 months (95% CI, 2.03-6.97 months), and median overall survival was 28.8 months (95% CI, 9.4-48.2 months). There were 2 patients with grade 3 (13.3%) anemia, 7 patients with grade 3 (46.6%) and 4 patients (26.6%) with grade 4 neutropenia, 4 patients with grade 3 (26.6%) and 3 patients (20%) with grade 4 thrombocytopenia. CONCLUSION: The repeating doublet of split-dose carboplatin plus gemcitabine reveals activity comparable to that of cisplatin plus gemcitabine, is well tolerated, and warrants evaluation in patients with recurrent breast cancer.

The incidence of four canals in maxillary first molars: a clinical determination.

BACKGROUND: The authors conducted an in vivo study to report the incidence of fourth root canals located and treated in maxillary first molars during a seven-month period in a postgraduate endodontic program. METHODS: In this retrospective study, the authors determined the number of canals treated by postgraduate students in an endodontic program. The attending postgraduate endodontic faculty member supervising the case verified the number of canals in the teeth. The authors then collected the data from each resident and compiled them. RESULTS: The residents treated a total of 121 maxillary molars, 85 (70.2 percent) of which met the criterion of having four or more canals treated. Approximately 99 percent of the fourth canals were located in the mesiobuccal root. CONCLUSIONS: Overall, 70 percent of the maxillary first molars contained at least four canals that required instrumentation. CLINICAL IMPLICATIONS: The results of this study demonstrate that it is imperative for any dentist performing root canal therapy on maxillary first molars to examine carefully the pulpal floor to locate all canals, especially the second mesiobuccal canal. Performing thorough examinations may increase the chance of treatment success.